EM Physician - Backstage Pass

9.08.2015

I remember how difficult it was for me to choose a specialty. Initially (as in before medical school), I wanted to be a dermatologist. I loved cosmetics and hair products, and as a college student I thought I'd go into some sort of 'beautifying' medical specialty.

Once in medical school they forced upon us that primary care crap tried to encourage us to consider careers in primary care. And I did...seriously. I really, really liked the idea of family practice. The doctor that sees the entire family, and watch the kids grow up, and have continuity of care, and keep the family healthy, yadda yadda yadda.

Then, I started having doubts. I met no one (even with all of this brainwashing exposure) who actually *enjoyed* family practice. It's a thankless job really. Anytime I asked a FP "do you like your job?" the response would start off "....wwweeellllll....". Not a good thing. And what followed was usually some combination of justification, hope, and regret.

So, I considered internal medicine. I guess I was stuck on this continuity of care issue, and thought that would make my practice worthwhile (you know, seeing the smiling faces of the patients I help, and eating the fresh baked muffins they'd bring with them to their office appointments to show their appreciation for my time and expertise). So, as a result of all the negative comments regarding primary care in general, I thought I would preserve my option of subspecializing (just in case the naysayers were right about primary care)...and internal medicine seemed better for that purpose than FP.

So, up until 4th year (FOURTH YEAR), I was all set to go into internal medicine. Then, in 4th year I did an elective anesthesia rotation. I thought about endless rounding that was internal medicine hospitalist care. I thought about the rushed office visits, and the lack of depth of knowledge (the "jack of all trades issue") and that kinda bothered me. What would I be doing all day as an internist? Rounding, taking call....clinic and referring? On the other hand...anesthesia pays well over $300,000 year, and you have only one patient at a time. There is no rounding, and the job is mostly low stress. And did I mention the over $300,000 yr salary??!!

I applied to BOTH internal medicine programs, AND anesthesia programs. I ranked anesthesia higher, and matched at my first choice spot. I did my prelim year in internal medicine...and off to anesthesia.

Well, I realized I hated anesthesia (at least my program sucked bigtime - which is no doubt detailed on this blog somewhere in another post). So now what do I do?

I didn't work this hard, for this long, and for this much debt to *hate* my job!!

I thought about my rotations as an intern. My ER rotation was the best. Not necessarily the most exciting specialty ever...but I just felt 'fulfilled' on that rotation. I felt healthier since I had time to get out in the sunshine on our days off. I felt disconnected (mentally and physically) with no beeper or hospital responsibilities on my time off...and the prospect of going back to work was exciting. Everyday I started with a clean plate. No inpatient ward 'rocks' or a patient that I was responsible for, yet someone else was just 'covering' for me. I enjoyed the 'we have a life' attitude of the ER residents. And I liked the fact that I could basically 'play doctor' with the patients until they became too complicated, or I became uninterested...then I could call someone else to take care of 'em.

So...I applied to EM programs (as a PGY2 anesthesia resident), AND internal medicine (in the case I didn't match in emergency medicine which was/is very competitive, I'd just finish up 2 more years in IM and be done). I guess you can say I decided on a EM career a bit late!! And even then, I *still* I wasn't completely sold...
***

I tell my story to demonstrate that choosing a speciality is very difficult indeed. With that said, I had a young woman send me a very thoughtful email:

I was telling my husband that I was really thinking about doing ER for the flexibility and the hours, because I'm really wanting to have kids......he responded by saying: I should do 'whatever I'm passionate about, no matter what the hours look like' because 'we didn't go through all of this to do something we're not passionate about'.

My Take -
Overall I think this is a very naive point of view. No, you don't wanna do something you hate. That wouldn't be fair...."after all of this time" you don't wanna go to a job everyday you *hate* (like me with anesthesia). But passion about a job.....??? I don't think that's a requirement at all, and if that's the *sole* determining factor in your specialty choice...you will be disappointed.

There is no way you'll *love*, say OB/Gyn if you cannot have your *dream life* because of it. Period. And, since being a 'part-time' OB is difficult....don't do it. It's kinda like buying a big house. Med students are basically telling themselves "you've worked hard...you deserve a mansion." So, you go buy a mansion....you're passionate about the house, and love the house....but after working 2-5 years around the clock, and never really having the opportunity to appreciate the home (or any other aspect of your life), you realize that you're just a slave to this house. Working to pay the mortgage....

...and you realize that you would be happier in a smaller house so you can work less and enjoy your life (and the small house) more. So, instead of finding joy swimming in your personal Olympic sized pool at your mansion (which you never had time to do anyway b/c you were working all the time)....you instead find joy swimming in the pool at the sports club you're a member of....and you actually have time to go and enjoy it.

Do you just absolutely LOVE your little house....??? Not necessarily. But, do you love your life...and the time this smaller home allows you to have free? Absolutely.

Do what you love. Love what you do!!

***

I don't like the lack of continuity with patients. I don't like not building relationships with families. I don't like the way it is in general...

My take -
I was very idealistic...."I wanna help people and build a relationship with them....". But, honestly, medicine isn't like that for most of us. Ask around...I think you'll find (I'm sure you'll find) that the *concept* of continuity of care is attractive, but the *practice* of continuity of care...sucks. You'll realize that, in your family medicine practice, you'll never see your "well patients" (the nice ones that do what you tell 'em to do...because they aren't sick frequently). And with all of your patients (in order to make a living) you can only spend 10-15 minutes with them (I get more time than that with my patients in the ER...and I actually probably get to know them better than their crazy-busy primary care doctor during their sometimes 6+ hr stay with me).

As a primary care doc you work long hours for little appreciation (and even less pay). And you realize that you'd rather have continuity of care with your own children, than with patients who don't listen to you, may actually sue you when they decide they have a bad outcome for not listening to you....and want it all for FREE!!

I say, continuity of care ideology is nice...but not the reality, and I wouldn't choose a specialty thinking that the continuity will be good thing.
***

I've never considered myself to be the type to gravitate toward "jack of all trades".

My Take-
Emergency medicine is the best of all worlds. No matter what area of medicine you go into, you will not be the most specialized person in the field. And doing the same thing everyday sounds very boring, doesn't it? If you're not a 'jack of all trades' you'll be seeing the same stuff your entire career.
***

"I don't think I'm an ER doctor type."

My Take-
Most of emergency is medicine is non-emergent stuff (so it's not like you'll be running around like on the TV show ER - of course depending on the hospital). In a given month (10-12 shifts) I may see 5 true emergencies. The rest is ruling out very unlikely things just to protect yourself (CYA), and urgent care/primary care things. I see these same people *way* more than I'd like - so there's the 'continuity of care' b/c they don't have access to primary doctors' offices.

Anyway, what is an 'ER type'? I think it's the type of person who values their time off...and realize that getting paid is important, and that life outside the hospital is more important to your health (sanity, and job satisfaction) than life inside the hospital. It's a person that realizes that having a dream life consists of balance, and that a job/career does not replace meaningful relationships (that require time and nurturing) with friends/family. That it is not necessary to become a martyr or forgo everything else to be a good doctor.

Now, what these ER types *do* with their time off...varies greatly (sometimes depending on gender).

Other pluses: you feel like a *real* doctor...not a technician or a pawn in a larger political game (at least not most of the time). And, you can always go work in a GP or walk-in clinic and see patients on an ongoing basis as a EM trained doctor.
***

Overall, it's important to remember (cuz lots of docs don't, and they are unhappy):You don't have to LOVE (every aspect of) your job for it to be the PERFECT job.

What ever happened to being responsible for yourself...owning up to your actions and mistakes, and holding yourself accountable for the circumstances of your own life? Sometimes I wonder, would people think I'm the most insensitive, uncompassionate, heartless doctor if they were privy to the ramblings of my internal monologue?

At King we have lots of traveling nurses. Mostly I welcome their presence because they bring "new insight" that lots of the native King nurses lack. Yesterday RN Wendell told me that I was one of the best doctors he'd come across in his travels. Other staff frequently gives me similar compliments...and the patients express gratitude, which is what makes it all worthwhile.

However, there are those people who...really are accustomed to doing whatever the hell they wanna do, with blythe disregard for consequences. And they need to be checked from time to time.

For instance, there's the 55 y/o alcoholic african american male, brought in by paramedics complaining of abdominal pain. History of alcoholic liver disease, gastritis, and chronic pancreatits. He reeks of alcohol, and is mildly intoxicated. We (taxpayers) spend thousands of dollars on his workup, and after 8 hours in King's ER, we determine he has acute pancreatits. Now, as he's sobering up, he becomes belligerent and demanding (specifically) demerol 100 mg IVP. What the hell?? Well, he's certainly not gonna get that from me tonight. After a couple of critical patients are stabilized he's up and fussing about how *we* can't let him just be in pain like this.

His response is "you bitch, I shouldn't have ever came to this fucking hospital."

Me: "Then leave." Did I go out to the street and drag you in here? Does he think he's hurting my feelings by leaving? (We actually call our yellow AMA forms "the golden ticket).

Him: quiet for a minutue "you alright doc...I'ma sit down...but how long do you think it'll be?"

Or the trauma patient who comes in all shot up. Dr. Spevack saves this guys leg after an extended operation. In the ICU the following week, the guy is pissed about...whatever...and starts going off on Dr. Spevack. "This fucking hospital sucks, you suck, I can't believe I got an infection...yo mama is a ho...so forth and so on." Dr. Spevack lets him finish...and then responds: "man, I fuckin' saved your leg and that's how you talk to me?"

With his baby's mama at the bedside he responds, "yeah, that's true." YEAH, asshole, that's true!!

So the above stated alcoholic decides to sign out AMA. "Well, I ain't got no where to go."

Me: You can't stay here.

Him: Well where am I gonna go?

Me: That sounds like a personal problem. You can wait in the waiting room until the morning, then go to a shelter.

It's a shame, but no wonder, that this guy has no-one to call. But if you were in the waiting room having an MI, you'd want to trade places with this guy too...so you can see a doctor, and he can come on out and deal with his social issues. His medical care is over, either by discharge or by his own choice, and the ER has limited space and resources. We need to get the sick people from the waiting room into the ER, and the not sick people out.

Or what about the lady who calls 911, is taken to St. Frances. Is triaged to the waiting room. Decides she's dosn't want to wait...goes outside and calls 911. Is taken to King. Is triaged to the waiting room (especially after EMS tells us she just left St. Frances). Leaves, calls 911 again so "she can be seen faster." What patients don't understand is, they are *seen* as soon as they walk in the ED. If their complaints are minor, or not as severe as the rest of the people, they wait.

Or the family who calls 911 to dump their mother anytime they wanna go to a movie. Or the woman who calls to "get rid of" her drunk boyfriend when he passes out drunk...again. Or the criminal who's caught committing a crime...then decides to complain of chest pain to avoid going to jail. Our EMS cannot refuse anyone a ride to the hospital...eventhough a few years ago they could. They used to assess a person, provide appropriate treatment, and if indicated, transport them to the hospital...consulting with the online physician if necessary. Too bad our society is so litigious and reactionary, because now they have to offer everyone a ride to the hospital, no matter the complaint or issue.

People come to the ER with their $400 i830 Nextel phones, in their Escalades with the Sprewell spinning rims, decked out in Fubu with Prada handbags...but can't pay 4 bucks for Tylenol to ease the discomfort of their 4 year old child...or pay $50 for healthcare or an ER visit? Who's holding these people accountable?

Or the government funding housing. It seems to me that if I (i.e taxpayer) give you a place to stay...I state the terms up front...you agree...then break those terms, you shouldn't get mad when I kick you out. No gang activity (graffiti, shooting/violence, felons hanging around with each other, etc) is a fair "rule." And even if it's not, you agreed to it. You're living in a place that I own, and you don't keep it clean, you don't follow the rules, and then have the nerve to get mad when I bring in police to "clean up" the place. It ain't yo shit...let's not get it twisted.

I'm not a left wing liberal, or a cross-hugging/burning conservative. I just believe what I believe, and whatever people decide to call it, so be it. Yes, there should be access to healthcare for everyone...but measures should be in place to hold people accountable. Granted lots of social problems that we face in the ED is simply a reflection of society at large..but they need to be dealt with.

She seemed okay after the questioning...and during rounds. But immediately after rounds she seemed to be sleeping. When the sheets were pulled back... .

..she was laying in a mound of dark red clots of blood. Looked immediately up at the monitor, low and behold she was tachycardic and hypotensive. The juniors were all over it...and stabilized her with IVF, blood transfusions, and even got a tagged RBC scan to see where the blood was coming from...exactly.

The RBC scan revealed a "sprinkler" in her descending colon. Surgery was called. They wanted an NGT lavage "the bleeding may be coming from above." But we have the RBC scan...

...initially the lady refused NGT lavage, but now she was intubated and unconscious, so it was done. No blood. Surgery was reconsulted.

"You have to get GI to see this patient first, she's too unstable for the OR."

GI was called...they can't scope until the following day (maybe). There's only one attending who scopes, and he's off today. Unbeliveable!

This went on all night. Patient seemed stable overnight, and the family was informed.

A CBC was ordered by the intern overnight...but the nurse (for whatever reason) decided not to draw one. Nor did he tell the intern. So there was no CBC overnight...and when I arrived at 7am, I ordered the (new day shift nurse) to draw one. The new H/H 3/10.

What!! How did this happen??

We order blood, which takes the better part of an hour to obtain...even noncrossmatched. We give her IVF, and talk the the (very surprised and upset) family. And we wait.

We call GI back...they are in clinic doing a procedure, and will come later in the day. What??!! Hello, we have a dying patient here... Candice the student nurse wipes the patients face because there is a bit of brownish liquid on her cheek. When she pressed on the cheek with the towel...more brown stuff came from the patient's mouth. So Candice picks up the suction and places it in the patient's mouth. Within 10 minutes there was 500cc (half a liter) of brown blood in the suction canister. 20 minutes later, there was 2 liters!! Surgery was called back.

No, we will not take her to the OR. She has an upper GI bleed, and GI needs to do endoscopy and control the UGIB.

GI...is still in the clinic.

Over the course of the following 12 hours, me and Mikey transfused this lady 20 units of PRBCs, FFP, platelets. We try everything...even the blakmore tube. The daughters are at the bedside watching us work (all damn day) tirelessly. Finally, when the lady's blood was as thin as koolaid, and it was obvious we could not keep up with tht blood loss...they asked us to stop transfusions. Lined along the wall was about 14 liters of blood in suction canisters. Blood all over the bed (nonclotting), blood on the floor.. . GI comes. We've already stopped. It's too late.

Surgery blames GI, they should have come earlier. GI states that it was too much bleeding for them to control...and hat she needed to go to the OR. Surgery states that they needed better localization of the bleeding site. I guess the tagged RBC scan wasn't enough. I guess endoscopy for localization of UGIB isn't something that's done in the OR at King. I guess GI doesn't do emergency endoscopy at King. I guess surgery doesn't operate emergently at King.

All an ER doctor can do is stabilize in a case like this. We cannot operate, or scope. And the hospital's way of doing business is allowing patients to just die in the ER...it's no wonder it's called Killer King.

The worst part......her 2 daughters, one 20 y/o, one 30 y/o, watched their mom bleed out. And no-one would do a damn thing.

67 yo Hm transferred from outside facility where he presented at 8am c/o severe abdominal pain with N/V for one hour. PTA his niece called the advice nurse who recommended she call 911. In the ED at the outside facility his work-up was essentially negative, except he continued having severe abdominal pain. Transfer was arranged to our facility because their CT scanner was broken. At the time of transfer, although all tests were negative, he was becoming increasing hypotensive/tachycardic. In fact, per family, the other facility refused to give him more pain meds b/c "his BP was too low."

Upon arrival to our ER, patient was hypotensive/tachycardic and c/o continued pain. He was pale, and generally appeared unwell. He was immediately transferred to our close observation area. Initial bedside ultrasound was performed, and negative. Blood was drawn, IV hydration given, and plan of action discussed with an already very frustrated family.

Although on exam his abdomen was not acute, he c/o pain out of proportion to the exam. CT scan ordered. Bedside ultrasound x2, no free fluid, aorta with no aneurysm. Surgery was consulted.

The surgeons were in the OR, and said they would be available in 1 hour. IV hydration continued, pain meds administered, and eventually dopamine had to be started. NGT placed, antiemetics given, and lab results checked. No significant abnormalities.

After 2 hours of resuscitation patient was still pending surgery evaluation. CT also still pending. Clinically, the patient is doing worse. Remains hypotensive on dopamine, and tachycardia worsens. Surgery recontacted, and ?still in the OR, will be down in 10 minutes - recommended the CT. CT called, patient wasn't due until 1930. Radiologist called to help expedite the CT. Before CT could be obtained, patient decompensated with waxing/waning mental status. Femoral line placed, packed RBCs transfused. Repeat bedside ultrasound done. No obvious free fluid seen, aorta not visualized, but there was a question of free fluid near the bladder (i.e. bladder vs. free fluid). Up until this time, patient with severe abdominal pain, but no guarding/rebound. Now, patient with distended, tender, belly with rebound/guarding.

Surgeons arrive at the bedside as PRBCs are being transfused and ultrasound being done. They evaluate the patient, and still felt the need to do a DPL. DPL revealed frank stool. Immediately went to OR.

Patient doing okay, but still intubated in the ICU.

My frustrations are: 1) Why did the advice nurse not tell the patient to go to a hospital that could actually treat his problem? Had he a AAA, I doubt vascular surgery would be readily available, 911 isn't always the best option. Sometimes getting into your car and driving to a facility that you know can take care of you is a better option.

note-to-self: don't listen to the advice nurse. don't sit around all day at a hospital who can't do anything, pending a transfer. Have someone drive you to another hospital.

2) What took surgery so long to come see the patient. If they had a case, there should be another surgeon who can cover the ED. Otherwise, the ED is non-functional (by everyone's standard).

3) how can the other hospital *not* have a working scanner. They should not be accepting paramedic runs.

4) Why does transfer take so long. It's so simple to say, a simple concept...'we'll just transfer her..' but hours it takes. Dead time.

5) Why does it take so long to get an emergent CT, even after attempts are made to expedite the study? A more expeditious CT would have revealed this problem sooner than clinical decompensation.

6) Why did the surgeons do a DPL? Had it been negative were they *not* going to take him to the OR? It was an extra step, and a waste of time.

7) Why doesn't the facility have mechanisms in place to deal with true emergencies? The CT backed up, the surgeons in the OR. I called surgery upon pt arrival to our ED. 5 hours later he's in the OR.

I really do care. I did all I could do. I covered him with antibiotics. I called surgery 2 or 3 times. I called them very early. Immediately after my evaluation, ultrasound, and speaking with family. They knew he was sick...hypotensive/tachycardic with belly pain. They knew and asked about AAA. Did they think the patient would just go away? Why didn't the surgeon send his resident down...to evaluate if he didn't 'believe' us. It's not okay to just not believe, and not come see...

I know I did all I could. I could not cut his belly open. I could not physically carry the surgeon to the bedside.

On the white coat.
Everyone wears one. I wonder why. I think patients are starting to realize that it’s actually those of us *without* a white coat that are the doctors.

On Customer Service.
How stressful would it be if you actually gave a damn about patient satisfaction scores. Not because it’s not a worthy goal to be customer friendly; but because these scores are derived from so many factors that you, as a doctor, have absolutely no control over. Wait times, parking, whether or not you have access to old medical records. Think about it, if a patient in the ED waits 8 hours, cannot tell the difference between a doctor and a nurse manager (because everyone is wearing a white coat), gets a CNA that treats them shitty, and then goes out to their car and finds a parking ticket on the windshield….you can bet that when a survey is sent to them asking them to rate their ED doc…they’re going to use this only opportunity, to show how frustrating it was for them. And when that patient decides to go elsewhere next time, it’s the MDs who are spanked.

On Complaints.
All complaints don’t deserve a ‘full investigation.’ The drug seeker who’s pissed off because I wouldn’t use my medical license, and my medical education/professional decision making capacity, to give him the drugs he seeks (i.e. I decide my job isn’t to serve as his drug dealer), he complains. Subsequently the wheels start rolling…and eventually I get to ‘respond’ to this complaint. Frankly, I don’t need to know about it…and the complaint should be discarded. The patient has the right to get a second opinion. I have a right (a responsibility) to do what I believe is correct/safe. Woe is the doctor who gets bullied by Anna Nicole Smith, and when she ends up dead…all eyes on doc drug dispenser. Customer service gone too far!!

I remember there was one case in particular. The patient wanted something that wasn’t medically indicated. Had I given it to her, and something bad happened, no one would have given me a pass because I was doing what she wanted. It would be like “but you’re the professional; you’re the one licensed to practice medicine; she didn’t know, but you knew better.” So, she went to administration and threw a tantrum. Some nurse administrator (in a white coat, no doubt) thought it was a good idea to walk the patient back over to the clinic, and question my decision. Needless to say, I felt very disrespected, undermined, and angry. “Why don’t you give her blah blah blah?” She asks.

“Because, in my professional opinion as a physician licensed to practice in this state, it’s not indicated, and potentially harmful.”

Her: “It’s not a big deal just this once to give her this or that….”

“If *you* think she should have it….*you* give it to her. You go to medical school, do a residency, apply for state license, a DEA number, and get a job somewhere…then you can give her anything you want. But, I’ve made my decision.”

Why did I have to go there?

On Joint commissions.
I wonder who appointed them, this private entity, God. Why are we closing hospitals, and compromising patient care, jumping thru impossible/impractical hoops trying to comply with various, random, and irrelevant ‘regulations’ that they pull out their asses. It’s easy to have a ‘new regulation’ on paper, but in practice, if it’s not practical to implement, it only distracts from what we’re actually able to do right. Also, what about when they’re just wrong, harmful to patients well-being. Like the 4 hour timeframe to antibiotic administration in pneumonia patients. I’ve seen more people with c.diff colitis violently ill, who received antibiotics to treat ‘possible pneumonia’, for the CXR to be clear. Passing out levaquin like candy in triage to meet some random joint commissions regulation is causing lots of undue sh*t (literally) both for the c.diff patient, and society in general as our antibiotic resistance rates rise. I think doctors need to take more responsibility, and *regulate joint commissions*. Afterall, who regulates them?

On universal health care.
When this happens…because it will…these groups that import doctors and nurses…who cut costs with cheaper mid-level practitioners in environments that should have physicians…who have unhappy doctors…had better watch out. CEOs need to understand: patients have health insurance to see me. Everyone else is supporting cast. Everyone else is there to allow me to do what I do.

On diversity.
You can’t advertise that you have a ‘diverse’ staff as a medical group/institution, if you’re counting foreign doctors/nurses, and minority/immigrant housekeeping and cafeteria workers as “medical staff.” When an Asian American, Mexican American, or African American patient seeks a diverse insurance company (i.e. anyone on staff that looks like them), they’re actually hoping for American doctors with various ethnic roots. The racial makeup of support staff…is very much less significant. And it is misleading to tout diversity in a medical group when the diversity you speak of doesn’t include the physicians…the very reason one seeks the services of a medical group/insurance plan.

On a Doctors Bill of Rights.
Doctors need a bill of rights. The right to do what they deem appropriate for the patients under their care. To prescribe the best medications, perform the necessary procedures. To refer to specialists as needed, and feel free to do the best they can without fear of friveouls malpractice suits. Doctors need legislative protection from insurance companies, CEOs, and other non-physicians hindering their ability to provide the very best care for their individual patients. Compensation needs to be fair. Medicare/cal, and insurance companies should not be allowed to short-change doctors for their own profit. Likewise, doctors should not be punished for providing medical care in the way of additional taxes. Tax the insurance companies who are making a profit (and those who are not). What sense does it make to tax the doctors? Why not the nurses as well?

These 'letters' were passed to me by colleagues. I guess I work with alot of...frustrated docs. (these were not written by me)

Dear Patient:
You came in at 11pm last night with a chief complaint of sore throat while munching on a sandwich at triage. Next time you choose a sandwich to bring with you to the ED, try something that will go down easier. Peanut butter and Jelly – while I’m sure was very tasty, made my ENT exam, well… a bit difficult. But alas, we did get through it and I got to see your very normal throat. While I was tempted to leave the diagnosis of “no real complaint” on your chart, after envisioning my directors review of yet another unbillable chart I went ahead and replaced it with “sore throat”. Your chart will be coded with a maximum of billing incompetence by our billing company. In their defense, they follow archaic laws meant to break my balls and keep money out of my pocket. I wanted you to know one last thing. It’s ok… you don’t really have to pay that bill. There will be no consequences. If it arrives at the (fictitious?) address supplied by you, you can chuckle as to how we could possibly charge $350 for doing nothing. I wonder if giving you a depot of 2cc’s of Bicillin into your deltoid would have made us both more satisfied. In the end, you provided for yet another priceless moment in this stage we call the ER.

***

Advice from an ER doctor to drug seekers

I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting but you might not be lying. (See below.)

The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can't get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me the fuck off. Pissing off the guy who writes the rx you want does not work to your advantage.

The fifth rule is don't assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won't necessarily mean you don't get any pain medicine. Hell, the fucktards who list an allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history, everyone in the ER from me to the guy who mops the floor, will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

The sixth and final rule is - wait your fucking turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier.

Me: "Hi Mr. Smith, I'm Dr. Gilman and will be taking care of you today in the ER. So, I reviewed your chart, and I don't see any significant past medical history. The nurses tell me you don't feel well. Tell me, what's the matter today?"

Smith: "I'm sick"

Me: "Okay, but what's wrong"

Smith: "I don't f*ckin' know, you're the doctor."

I hate, hate, it when a patient doesn't have a chief complaint when they come to the ER.

Why are you here? Today? Right now? (i.e. why couldn't this wait until you could see your primary doctor). What changed? What are you afraid of? Specifically, what part of your body is bothering you.

My job is to determine if this...whatever it is you have...is likely to kill you tonight, or tomorrow. If it won't kill you (or severely disable you), my job is done. I do not know why your rash won't go away. I don't have the time or resources to figure out why your toenail fungus medication isn't working. I don't usually adjust medications that your doctor has decided are best for you. And I don't write prescriptions for psych meds, viagra, or refill highly addictive meds without good (and I mean a very good) reason. I am not a substitute for your doctor. If you rely on the ER to diagnose cancer, or manage your hypertension...you'll die from complications related to these diseases. You could go to the ER 10 times in 2 weeks c/o abdominal pain, that eventually turns out to be an gastric ulcer or stomach cancer. Do you know when we, in the ER, will make that diagnosis? Never. Or, not until we see a big hole, or a big mass, on CT. By then, it's end-stage. And to think...you've been coming to 'see a doctor' for weeks.

And another thing: people who 'save up' their medical issues, and then complain of everything under the sun when they go to the ER, bug us. In the ER, you get ONE problem. Choose carefully.

I wish patients could understand the limitations of the ER. I wish patients would think about why they've decided they need emergency care. And I wish they would limit their complaints to 1) emergencies, and 2) one basic problem.

Still living in an era of the rich, private practice mentality...not accepting the fact that most physicians today are employees in one way or another. And instead of turning up their noses to unionizing, perhaps they should realize that they are now more like the average worker. They've allowed the nursing union to be the be the sole legislative voice on healthcare policy, to their detriment, and to the detriment of their patients.

As the nursing union shouts "patient advocacy," they are trying to implement healthcare policy that actually hurts the poorest, sickest, neediest members of our society (I'll elaborate as needed). The whole while, the AMA/CMA (made up of mostly people who are completely out of touch with young physicians) asks for money, but does nothing to help their cause. Time after time, taking "no position" on matters that make a huge difference with regard to modern physician's issues. Case in point - the Governor's proposed tax on doctors and hospitals. The doctor's are getting fucked, and there is no unified voice advocating on their behalf. Therefore, patients are getting fucked, and healthcare is a complete mess. And where are the doctors? Where is their voice. What solutions are *they* offering?

Doctors need to change their thinking, hold the medical societies accountable, (or refuse to join), participate in the legislative process, and drop the arrogance against unionizing. Or we can all prepare for complete chaos as healthcare continues to fall apart, without a legitimate beacon of leadership. As the doctors bury their heads in their arrogant asses, allow everyone else to take control, and then wonder why they are (directly) paying for a shitty healthcare system, run by nurses/chiropractors/optometrists/herbalists/and the 'people at the healthfood store.'

In the hood, lots of folks are looking for a payday. Be it by "falling down" at the grocery store, or selling things on the street that....sell. A great number of people bitch and complain about paying a $50 copay, but pull up in a pimped out Escalade with spinning wheels and a $400 cell phone. The ultimate consumers.

Well, in medicine this trend continues. And, apparently, many of the frivolous lawsuits are initiated by people just looking for a payday at someone else's expense.

At the Kingdom, there was this young guy...who was racing his motorcycle on the freeway. He fell, got crushed, and was brought in to our trauma center. The surgeons patched him up, but after a month long ICU stay (and hundreds of thousands of dollars in bills paid for by you and me), he still couldn't walk. He had a pelvic fracture that required a 'special' (complicated) orthopedic procedure to *possibly* correct his problem. There were only a couple of orthopods in the city who performed this procedure. The issue was, the 'complicated' surgery was very labor intensive, time intensive, and the end-result was based largely on patient compliance...and evenso, the results were unpredictable. The surgeon was concerned that the patient: 1) wouldn't/couldn't pay him, so he'd be working essentially for free. 2) then the patient is a dumbass, and will probably *not* be compliant with follow-up 3) and finally, when the results weren't what the patient expects (which would be 'perfection' and the ability to get back on his bike and crash again)...he'll turn around and sue the surgeon.

So, here is a patient...that no orthopod will touch. It's not worth it to the surgeon. This is a skill that he has spent years, and hundreds of thousands of dollars, perfecting...and to not only *not* be compensated for it...but then have to *pay* in the form of a lawsuit, for an expected complication/outcome...just didn't appeal to these guys. So...this patient, 3 years out from his accident, is still unable to walk...and no one will even attempt to correct his problem.

***
Then there was the guy that presented to the ER after some quack manipulated his spine, causing a rupture of his vertebral artery (in his neck). All the docs saw *lawsuit* on this patient's forehead...and he died because no one wanted to get involved. No one wanted to perform an intervention....and have the patient die as a result...only to have to explain to a jury (a group of folks with no medical knowledge or experience), that he did nothing wrong. So, all the subspecialists sited one contraindication or another to avoid getting involved. And, of course, the patient died.
***

If I ever get hurt, I hope I can convince the doctors taking care of me that...

*I will not sue you if you do your best...even if you make a mistake...even if the outcome is suboptimal*.

If you can do that...convince the doctors that their best is indeed good enough...you'll get (better) care.

I've worked at more than a few places...both EDs and urgent cares. I can finally say I now fully appreciate the difference between a 'physician efficient' ED and...one that's not.

One of my gripes about working in the ED as a doctor is...the place isn't set up to maximize physician efficiency. Sure, they expect you to see 2.5 patients an hour...but when it takes 20 minutes to log into the various computer programs, trouble shoot the printing process, and then find said printout to sign and place with the chart (if you can find the chart)...there's no way the "goal" of 2.5 patients can be reached.

Let's take last night...
...there were 4 docs there, only 2 computers available for our use. My kindergartner can tell you that 4 docs need 4 computers. As everything is computerized now, I can't even look up lab results, or discharge a patient without using the computer. So, I found myself standing...waiting...for a computer to open. While patients have been in the waiting room for 6 hours or more. Then, when 'productivity' scores are released, it seems we're just...slow. And to compensate for the utter inefficiency of the system...doctors are expected to 'just speed up'. Making an already stressful, high-liability, acute situation...even moreso. There are only so many corners you can cut. So, some of my colleagues will opt to stay hours past their shift, doing charts, and continuing to dispo patients...stuff that they should have done hours prior (which would be both better for the patients we've seen, and for the patients in the waiting room), but couldn't for fear of slowing down...and being the "slowest person in the group." So, the patients (all of them) endure less than optimal medical care.

Why do we let them punk us like that? 10 hours of work should be done in 10 hours. It should not be expected/required that you do 12 hours of work in 10 hours. If the system is so inefficient that only 1.75 patients/hr can be *properly* seen...that's how many we should see. And charting/paperwork shouldn't be saved until the end of the shift. Documentation as you go is more accurate, and provides better communication to consultants and other healthcare team members. Above all, it allows you to keep everyone straight, and demonstrates real-time decision making and outcomes. Not to mention it's a total pain in the ass trying to gather all the pieces of information needed to compose a good note...after the fact.

So, what have I noticed that distinguishes 'efficient' EDs from 'inefficient' ones?

1. Smaller is better. The new trend is to build these 'mega emergency departments.' Where everything is spread out...very pretty...but inefficient. If you have a large ED, you need to break it down into essentially 2 completely different departments. Where one doctor is in one area...period. Not theoretically, but actually. There are EDs where the idea is to have one doc in an area, with a couple/few nurses...and that's where they stay for the entire shift. But in actuality, the doctor's patients are placed all over the place...in various areas...depending on "which nurse is up next to receive a patient." Additionally, the beds fill up in a particular area, depending on the disposition of the patients, their acuity, etc. So, patients will then be placed...anywhere there's room. Seems logical on the surface. But, then you have a doc running around this big ass ED, trying to care for patients from one corner to the other. This is inefficient, and slows down the flow. This ultimately is not good for patients. If the ED were to be divided (physically divided) into 2 discrete entities, this would not happen. Kind of like how Starbucks will frequently put 2 (separate) stores right across the street (or around the corner) from each other. It just works better...not having a huge, inefficient, chaotic, place to conduct business - but rather 2 (or more) completely separate places of business.

2. Each physician needs his/her own work station. As demonstrated above, it is a bad idea to require the usage of computers with not enough work stations. Waiting in line for a computer...isn't conducive to ED flow. And, not just random computers should be available...but rather each doc their very own. That way, you can set up the computer...log in...and not have to worry about getting up for a second...and losing your spot. Additionally, I could argue that this is better for patient privacy.

3. The computer should stay logged on. I'll approximate that I spend 30 minutes a shift logging on to various programs...each of which shut down after a couple of minutes of "idle time". Another joint commissions bright idea, I'm sure. HIPAA, CMS...someone who doesn't understand the practical impact this has on ED flow and subsequent patient care. The computer should be in a place that patients don't have ready access to. Once I log on, I should stay logged on. Perhaps there should be a way to tell the computer how long I'm working, and to log me out at the end of my shift. But logging on every 2 minutes...is not the most efficient option.

4. Speaking of logging on...can I have 1 login name and 1 password? Currently I have like 4 different login names/passwords. So...I end up writing them all down in my pharmacopoeia. I also see people put little stickies on the side of the computer. It has to be 'safer' and 'more protective of patient data' for me to have 1 login/password in my head versus all my info in a book...or on a stickie pasted on the side of the computer!!

5. And, can we quit changing the passwords every 3-6 months. This is another reason you find passwords on scraps of paper, stickies on the computer, or written in frequently lost pocketbooks.

6. Decrease the scut. Can we hire a clerk, high-school student...anyone, that can load the printer with paper, keep the necessary documents stocked, and print out aftercare instructions and acquire the patient's signature? I do so much scut...it's no wonder patients wait for 6 hours. It takes hours of my day printing pieces of paper, signing them, and placing them with the chart (after finding the chart). When my lab results are available, put them with the chart and notify me. When my radiographs are done, do the same. If an extended period of time has passed, and the data remains incomplete, call the lab, call the xray tech...find out what's going on, and fix it.

7. Have ED techs set up procedures, irrigate wounds, gather equipment, etc. And when rooming a patient, place them in the appropriate space. ENT, eye, Gyn, etc.

8. Have the nurses take less breaks. Man, they are *always* on break. I must say, I'm very jealous. We get no breaks. I can't even urinate or take a sip of water during many of my shifts. They get like a 45 minute 'lunch' and 2, 15 minute breaks. I can only dream!!

9. I need necessary work items in my work area. Can we have needed documents, trash cans, printers...you know, the things we need to work, near our work stations - and not solely across the way in the nurses station? It is a poor use of my time to make multiple trips *per patient* to the island for supplies when those very items could be placed in a spot more convenient for me.

10. The location of my patients matter. Ultimately, the flow of the ED, how many patients are seen, and how quickly they are dispositioned depends on me. And if things are not set up for me...the ED doesn't work well. Ancillary staff and nursing are important...but so am I. That needs to be taken into consideration. It's easy to understand why the nurses need their patients together, so why would it be any different for the physicians?

11. Don't bring patients back from the waiting room until they are ready to be seen. Bringing a patient from the main lobby into a smaller waiting room is a stupid idea...and only serves to frustrate the patient. Just when they think they're going to be seen, it's more waiting. Kinda like being in line at Disneyland, going thru the maze...thinking you're finally at the front of the line...turning the corner only to see a brand new maze. This frustration on the part of the patient only serves to slow us down...and lowers customer patient satisfaction scores (for those in admin who seem to get a hard-on over such things). It doesn't help when patients are constantly coming out of their rooms (or this "inner waiting area") to bitch and complain about the wait. It just slows us down even more. The lobby is a perfectly fine place for them to wait.

12. One thing that worked well at one place I worked: have the clerk call the medicine consultant. We, physicians, requested a medicine consult by asking the clerk to obtain one. She wrote the patient's name, chief complaint, and a 1-2 line "reason", that we provided, on the book. When they returned the call, she gave the consultant that info, and they came down. If they had questions, or we had a more acute patient, of course we'd be more aggressive and communicate more directly. But for the routine 'chest pain r/o MI' on a patient that you know didn't have an MI, but you can't send home because 'what if he did?'...this process works well. And most of our admissions are more or less well-appearing, low risk, CYA, bullshit...so, why fake the funk? Why waste time calling medicine and hanging around until they return the call for these patients? It's not like they won't come see the patient. The process is streamlined, and it works very well.

13. Writing holding orders for admission works well.

14. Paperwork. There's absolutely too much paperwork. Documentation, is done for billing, and less so for patient health information communication...which is unfortunate. Much of what we write is irrelevant, but required for payment. Therefore some medically pertinent items are excluded...because there just isn't enough time to do everything. Decrease the number of sheets of paper, and the amount of random bullshit we need to include for payment, and things will move faster.

And finally an ED Wish
I wish I could go out to the waiting room and tell people "Look, tonight is busy...and if you're not very sick, the wait is in excess of 5 hours. We'll see you, but don't ask us 'how much longer?'" It seems appropriate to tell people the honest answer to that frequently asked question ("How much longer, I've been here for 3 hours already?")...but we don't. We say "ummm, weeelllll, it depends on how sick people are....I don't know exactly....yadda, yadda, yadda", when in fact we absolutely know that it won't be in the next 5 hours!! We did this a few times in residency...and the ED waiting room cleared out. Non-urgent people left, and the emergent people got better care. I also heard about UC Davis doing this rapid screening (meeting EMTALA) then sending people out *from triage* if they were non-emergent. The only thing is...the paperwork is a rate-limiting factor, even in a 'rapid' triage system. If that could be stream-lined....the ED would work so much better.

Getting feedback from those of us *actually working in the ED* is the best way to make things better!!

3.09.2012

Not for themselves, not for their patients, and not for their profession.

Gradually (and not so subtly) everything non-medicine has played increasingly larger roles in interfering with the doctor-patient relationship.Everyone suffers (even those greedy bean-counting executives suffer when they finally succumb to their own illnesses, or as they deal with trying to navigate American healthcare for their families). And instead of demanding a seat at the table, exercising their responsibility to weigh in on all things medicine...they sit on the sidelines and complain.

But this is beside the point.

My point today is to talk about whether or not choosing emergency medicine (or even choosing a career in medicine) is what I thought it would be.

Let’s start with what I thought it would be like.

***

I knew, as a medical student, that my role was insignificant.I knew residency was hard with long hours and physical exhaustion.I understood that college and professional school would be expensive (and accrue a large debt for a girl from a non-wealthy family) and residency would mainly serve to delay my ability to pay off these debts.

I recognized that I was socially underdeveloped, and had no practical knowledge about anything not in the lecture notes.I expected to wait to have a family, and accepted being continually absent from my own life to undergo this training program.

However, I also expected more freedom once done.I hoped for enough money (which is subjective and constantly changing) to live comfortably. I hoped to reclaim some “lost” time (and hang out with friends, read some novels, get married, have kids).I hoped to mentally *graduate* from student status, and buy a big-girl house, and big-girl clothing.

Most of all, I thought there’d be more appreciation and respect for the sacrifice doctors make in order to do what we do.I hoped for a more powerful voice as a professional.I thought doctors and patients would advocate together for the best possible health-care situation. (Vocal in a 'I am woman, hear me roar' kind of way...sorta like the nurses. I guess medicine is still too male dominated to be very vocal....)

But what I quickly realized was…

…being a physician is not quite what I expected.

But I’m a roll-with-the-punches kinda girl (or at least I try to be), and realize that physicians are *still* quite cool.Saying you’re a doctor does offer a certain degree of legitimacy in conversation…and it is easier to get a ‘seat at the table’ if you bring a medical degree with you.I do acknowledge (and appreciate) that.

Instead of complaining (further) about all the things “wrong” with being an ER doc, let me make it clear…

…it really is a fabulous job.

Not a day goes by when I don’t get some fantastic job solicitation (usually in not-quite-so-desirable places to live) begging me to consider a move to Podunk, Wherever, for crazy sums of money.And even locally, having board certification in a specialty that everyone uses makes finding decent job a small issue.There’s never a shortage of ‘business’ as an ER doctor.As the recession progresses (and the economy slowly recovers) our ‘business’ just increases as people lose their health insurance along with their jobs - which is unfortunate. But single payer would allow everyone to have access to (at least minimal) medical care...and (get this) we'd actually get paid for said care. (I honestly don't know why doctors, especially primary care and first-responders, would be against getting *some* compensation from *everybody* you serve)....

...but I digress.

What I do in the ER, matters.It is meaningful work.And the pay is not bad either.

I often get asked:would you recommend this career for your children (or some variation thereof).

The answer is (still) absolutely yes!!But with caveats.

I think it’s important to go early, go hard, and get done.Doing it this way, you could be done with all your training by age 29.Still plenty of time to “catch up” on everything else in life.After all, what better way to spend your twenties than setting yourself up professionally (and possibly financially) for the rest of your life.All before you have children, get married, or acquire additional responsibilities (such as elderly parents) or in society.

I think it’s important to focus on the practical aspects of choosing any career, medicine included.It is not “a calling” or some sort of “special” state of being.It is a career.A way to make a living and contribute to society professionally.Just like a photographer (with better pay)….or a plumber (with equal pay).

Realize that having a fantastic career (any career) will not adequately replace loving relationships, family, and personal development. Temporary sacrifice is expected of many low-rung staff in any career…but constant/permanent sacrifice is not worth it.

If you put off having a family, miss your grandmother’s funeral, miss your cousin’s wedding…and then, at 35 realize that you cannot conceive…medicine would NOT have been worth it.

Everyone has their own ‘balancing act’ to achieve.Some of us put more emphasis on family…while others lean more towards career.That balancing act is highly personal.I will say, it’s very easy to weigh career more heavily (even when you don’t intend to) because of external pressures and the societal value placed on wage-earning and 'work' – especially for the “liberated woman.”

If you’re not careful, you’ll become imbalanced, convincing yourself that you’re where you want to be…even when it’s not.And…discontent sets in.

But, if you are able to put “everything in its proper place” in the ranking of your life priorities, medicine can be an excellent career. And EM...allows a doctor to do this. To work a lot...or work a little.

There are days, nonetheless, when you think to yourself...

....what *else* might I be good at? Is there anything else I might want to do?

1.04.2012

When I was a medical student there was a girl who, after 2 years of medical school, decided…she didn’t want to be a doctor after all! I remember hearing a rumor that she decided she would rather spend her days swimming with dolphins. Then…she was gone.

That got me thinking, for the first time in my life actually, what do I WANT to do? Prior to this, my standard reply of “I want to be a doctor” achieved sufficient accolades from everyone, and the satisfied look on their faces served as confirmation that I was on the “right path.” I never really gave it a second thought. But this girl…had the audacity to decide on her own that she was going to “throw away” everything she’d worked for (and all the sacrifices her family had made to allow her to opportunity to attend medical school) and make the “irresponsible” choice to swim with dolphins in lieu of becoming a doctor. I mean, who does that?

At that time, I thought to myself: good for her for knowing what she wants to do, but why not finish medical school first, *then* go swim with dolphins? That way, if her perception of a dolphin-swimmer’s life was misaligned with the reality, she would have “being a doctor” as a back-up career option.

So I spent no further time pondering any other choice at this time. Instead of thinking about what I *wanted* to do, I focused on completing the path I was on, because that’s what made sense to me. I reminded myself that the most difficult (academic) work was complete after taking the USMLE Step I (after 2nd year). The third and fourth years were the clinical (interesting, “field-trip”) years, where you *finally* get to legitimately “play doctor” for real! Why quit now?

But *when* IS a good time to quit? Once you get on the ‘medical-training-in-America’ highway, there is no “easy” time to deviate. It makes sense to complete medical school because once you achieve your advanced degree, you can *still* go fold jeans at The Gap if you want. Nothing (but a few years) is lost by finishing the degree program. So you finish…

Then, you can’t quit before internship. You can’t even get a medical license without completion of an internship! It only makes sense to obtain licensure. Why go through all of that training (and torture) in medical school to become a doctor, and then take away your ability to actually get a medical license because you’re too “lazy” to do just one more year?

Unless you know something that I don’t (which is quite possible), there’s nothing you can practically do as a new doctor (with no other training) without residency completion. You can’t really make any money (and with the huge burden of student loans, *choosing* to NOT make money is a crazy option), aren’t respected as a doctor, and are ostracized completely from “real” specialists (and everybody’s a specialist these days). Who wants to sign up for that? When in just 2 more “short” years, you too can be a board eligible specialist! So…I made up my mind that I would complete the entire training program, and *then* I could reevaluate my decision from a position of “safety” – as a board certified physician specialist.

As a 4th year student contemplating specialty choices, I decided *then* that (despite everything I thought I knew about myself) I had no desire to spend significant time taking care of sick people – gasp! And this realization just kind of snuck up on me as a senior medical student.

Before medical school I thought I wanted to be the quintessential doctor who took care of the entire family their entire lives, family medicine. Then I realized that people are “difficult” and I do not want to be ‘responsible’ for people, sick people…and certainly not their entire lives! Whose crazy idea was that in my head all those years, thinking I could pull that off?

So I eliminated the kids and pregnant women which is essentially internal medicine. That felt better. But still, too big. Too much. Too long. But, nothing else was particularly appealing, and this late in the game many options are essentially removed from the table. So IM it was. But then, I signed up to do an anesthesiology rotation because I’d heard it was super easy…and after 3.75 years of medical school, I was so ready for easy!

True to its reputation, the rotation was a cake walk! Show up at 6am (which was the most difficult part) and intubate a patient or two, then go “read” (i.e. do whatever) until the next morning. There was the opportunity to see trauma anesthesia, which allowed the student to do a-lines, venous lines, and more! Very cool stuff! Still not completely sold on my IM choice, I switched to anesthesia, just like that. I was desperate to “find” my “place.” I was a gypsy, and even as 2nd semester 4th year (senior) student, I was uncommitted!

So I clung to anesthesiology. Sure, I was cognitively aware that I would not be able to intubate and leave. I realized that the days began very early, and were long. Call was busy, and the training stressful. But, I *also* didn’t have to take care of a bunch of people…forever. One patient at a time. Done with surgery/procedure, done with patient. Sounds perfect.

Let me say, it is about this time I began to awaken from the unconsciousness of whirlwind academic overachievement and hierarchal indentured servitude, and realize that “maybe this whole doctor bit is overrated by those *stuck* IN it.” As a coping mechanism, I think many doctors just don’t *think* about their lives, and are unable to consider alternative life paths because they subsist on the delusion that this way is the only way to “be somebody.” And it doesn’t help that doctors typically see themselves as professional corporations and not the workers that they are, so their work conditions are super shitty, but no one cares. Especially not the doctors.

But I digress.

As an internal medicine intern (required prior to starting my anesthesia training) I actually had a great time. Becoming an intern is, in many ways, the prize for years of hard work and being invisible. Years of proclaiming “I’m going to be a doctor on day” to finally *being* a doctor is a huge step forward. Because, honestly, how many of us know someone who’s “going to be a doctor one day?” Not a big deal.

Just *finally* being the DOCTOR was enough positive momentum to sustain me through the internship year. And the amount of practical knowledge I acquired was worth the “abuse” and “sleep deprivation” at that time in my life. I felt legitimate (although incompetent). Also helpful was the knowledge that I was moving on to ‘bigger and better things’ with anesthesia. I was NOT going to be “doing this” (rounds, carrying a pager, writing long H&Ps, the whole deal) much longer. I was going to do short notes, cool procedures, and sit on my ass all day as an anesthesiologist listening to uplifting music, reading trash magazines, and getting paid well. Couldn’t wait!

So you can imagine my disillusionment when I actually began the anesthesiology residency. It was early mornings and long days. It was being on-call and lack up sleep. It was lonely. And in some respects, demeaning, boring, yet stressful all at the same time. And, the worst part was (for me) – there was no one to talk to, and minimal patient interaction. Who knew that taking care of sleep people would be lonely and impersonal?

Clearly, I hadn’t thought out my specialty choice well.

What now? I don’t want long term relationships taking care of sick patients. I don’t particularly like small children (even more so before I had my own). Being all up in vaginas all day was the *last* thing I found appealing. What else is there? Maybe I would go back and finish IM, and then subspecialize? But that would tack on like 5+ years to my training, and after this whole fiasco, I had no time for such nonsense. After all, I’d been trying to find an exit off this medical highway since 2nd year medical school, but stayed on for very logical and practical reasons. But at some point, I just had to draw the line.

It is important to keep in mind that doctors have done themselves a huge disservice by subscribing to the current status quo of medical training. Unlike nurses, or PAs, we cannot just “switch” specialties and “do a new thing” when we get bored with the current thing, or otherwise we can no longer do certain procedures or function in certain capacities. Nor can you move to another part of the country on a whim and expect be granted a medical license from another state (never mind the fact that you already HAVE a medical license after passing a *national* exam, which is asinine and a post for a different day). For multiple reasons it is not practical for a mid-career physician to “go back” and do another residency to obtain different credentials to do a new thing. Overall, medical education does not easily extrapolate into meaningful work outside of medicine. So, once you choose a specialty, you’re essentially stuck! A decision you make about your career at age 25 had better serve you well when you’re 50.

Oh, the pressure!

After all of this, I decided to pursue emergency medicine, primarily because it allows doctors to be doctors when they want to be doctors – and cool doctors at that. But, when you didn’t WANT to be a doctor, you could do something else. Anything else! And still be cool. With a solid “back-up” plan that is EM. And the cherry on top of that sundae was: I didn’t have to take care of sick patients for forever. I can step in when they really NEED help, I can TALK to them, I won’t be lonely, I get to do cool stuff….and then…I get to go home! To my life. All the while, making 100% more than a pediatrician, and 50% more than FM with less stress, less work, less ‘distraction’ from my REAL (non-doctor) life. (And judge if you must, but money *does* matter, especially when the cost of medical education is in the hundreds of thousands of dollars!)

11.09.2011

Medical school memories came *flooding* back as I read Anthony Youn’s memoir, In Stitches.

Medical school was a time in my life where the details are sketchy because it was a blur of studying, isolation, anxiety, frustration…sprinkled with intermittent moments of fascination and joy.I can completely relate to his thoughts about pediatrics, “Little people, little dollah”, and being torn between life-style specialties and being a “real” doctor.I shared his dislike for the standardized patients and the weirdness that entire situation evokes in all of us.

My favorite aspect about this book is its honesty and authenticity.As I devoured the book chapter by chapter, I felt like I UNDERSTOOD Tony.I was able to peek into a life very similar, but very different from my own.His book was truthful, the language was clear, the humor and candidness kept me interested and I really felt like I traveled this journey with Tony.As I read the pages, I thought of my OWN similar experiences….and my reaction to them.And as I flipped the page….reading his words were like reading my own mind.It was quite amazing!

There were only two questions that stayed with me through-out the book: Why didn’t his family help him acquire better living conditions?And was he really a virgin until medical school?(implied, but not stated)

I will say that I feel like the first part of the book would appeal more to young men, with all the talk about girls, women, and overall “manning up.”Since women do not (typically) go through this, it’s all very foreign in an annoying kind of way (as a woman).I was much more interested in…all the rest.Thankfully there’s plenty of ‘all the rest’ and the book was thoroughly enjoyable.

I would LOVE to read a “part II” plastic surgery residency memoir.It really was *that* good!

About Me

I am a (not so new anymore) emergency medicine attending. (And now that I have time) a Mommy, a wife, a budding photographer, a part-time dog trainer, an "urban farmer," a sorority girl, a web-site designer, and ultimately a spiritual being having a human experience...who's interested in living an peaceful, purposeful, authentic life!
Contact me at ERbackstage@yahoo.com

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Let me save you the trouble of trying to identfy patients on this blog........don't. They are not real. The cases are made up. Some even taken from the tv show ER. Some are cases I hear about on the news. Grey's Anatomy, or even House MD. I have real ER experience, but there are endless clinical scenarios to demonstrate my point without basing my story on actual patients. There are no HIPAA violations on this blog.